Clinic Name Prescriber Name NPI# Contact Name Username Contact Name User Email * User Password * Confirm Password * Clinic Address Line 1 Clinic Address Line 2 City State ZIP Code Clinic Phone Disclaimer *I understand and agree By submitting this form, you certify that the information provided is true and accurate, that you are a licensed medical provider acting within your lawful scope of practice, and that all compounded medications ordered will be for patient-specific prescriptions only, in compliance with all applicable state and federal regulations governing 503A pharmacies. Clinical decisions, prescribing, and patient care remain solely the responsibility of the authorized provider. A current copy of your active medical license is required and must be submitted for account approval. Duplicate, altered, or expired credentials will not be accepted. Print Full Contact Name * Submit
